The purpose of this proposal is to provide Dr. Amber Barnato with the means and structure to transition to an independent investigator. The candidate is a new Assistant Professor at the University of Pittsburgh with fellowship training in health services research. Her long-term career goal is to conduct and disseminate research that informs Medicare financing policy and the delivery of health care to older Americans, motivated by the coincident rise in technological capabilities of health care and the expected doubling of the population over age 65 by 2030. In the context of this career award application, which contains a well-defined curriculum in quantitative and qualitative methods and has the institutional support of a highly successful Division of General Internal Medicine and the commitment of practiced mentors Drs. Derek Angus and Judith Lave, the candidate will study hospital-level variation in treatment intensity at the end of life. Regional analyses demonstrate that elders in Miami spend twice as much on health care in the last 6 months of life as those in Minneapolis and are 4 times more likely to be admitted to an ICU during that period, without any measurable outcome benefit. Studying hospitals, rather than regions, may be more informative since they are where clinical decisions are actually made and most likely to be influenced. Yet there is very little hospital-level research on end-of-life care, and that which exists is limited by focusing only on patients who have been retrospectively identified as decedents, having data on too few hospitals to be more generalizable, or focusing only on patients already admitted to an ICU. Using a single state with uniform regulatory and reimbursement structures and an unusually clinically-rich hospital discharge database, this study will: 1) Measure hospital-level rates of ICU admission and intensive procedure use in Pennsylvania; 2) Identify the hospital-level correlates of intensive treatment at the end of life; and 3) Determine the effects on survival and inpatient costs of varying hospital treatment intensity. This is a secondary database analysis augmented by primary data collection at the hospital level. This research may help to identify policy-relevant organizational factors that can be influenced to improve the care of older Americans at the end of life. This award will facilitate the candidate's transition to an independent health services researcher will lead to future funded studies and quality-improvement activities in Pennsylvania hospitals.